What are veins?
Veins carry blood from the extremities, tissues, and organs back to the heart. They have relatively low flow and low blood pressure when compared to the arteries that carry blood to the extremities, tissues, and organs.
Our legs are comprised of a network of veins that are similar to the branches of a tree. It is the job of our veins to carry oxygen-poor blood back to the heart so it can be cycled through the lungs and then pumped back to the body. Healthy veins have valves that open and close to assist the return of blood to the heart. Venous disease (also called vein insufficiency or venous reflux), occurs if these valves become damaged, allowing the backward flow of blood in the legs. Because gravity works on the legs more than on other parts of the body, these vein valves can become leaky and allow blood to flow backward into the leg leading to a feeling of heaviness and fatigue, causing varicose veins. Over time, this can cause additional valves to fail. If left untreated, it can lead to leg pain, swelling, ulcers, and other health problems.
Problems in the Veins:
2 main problems that can happen in the veins
Obstruction: Obstruction of the veins can be caused by blood clots, scarring or compression by a tumor. If a vein in the leg gets obstructed, the person develops leg swelling and sometimes pain. If it stays obstructed the body tries to form collateral that are often known as varicose veins.
Reflux (or Venous Insufficiency): Reflux occurs when the blood flow in the vein goes the wrong way through incompetent, or leaky, valves. When flow in a vein reverses it increases the pressure in the veins and can cause swelling of the extremity or dilation of veins. When there is dilation of veins beneath the skin they are called varicose veins.
What are the symptoms of vein disease?
Lower extremity swelling.
Tingling, aching, fatigue/tiredness, cramping, restless leg, pain
Itching of the extremity
Prominent tangle of veins at or under the skin (varicose veins)
Discoloration of the skin
Pain due to inflammation (called phlebitis).
Varicose veins due to venous reflux. What can be done?
The first step is to treat the underlying cause or reflux of venous blood. This is done by obliterating the veins with leaky valves that permit blood to flow backward. In most cases, there is a superficial vein called the Saphenous Vein that is abnormal. Obliteration of this vein does not require surgery, and there are now many different techniques that all work to treat the saphenous vein including laser, radiofrequency, sclerotherapy. Once the reflux has been halted, the varicose veins are less engorged though they may still be unsightly and require removal.
Treatment of unsightly veins. Large ropey superficial varicose veins can be removed through a very tiny incision. This is called phlebectomy. Very small veins, called “Spider Veins,” can be treated by injecting them with a small amount of sclerosant.
Deep veins and clotting. What can be done?
Clotting within the deep veins, or Deep Venous Thrombosis (DVT) is a common problem in the United States. Hundreds of thousands of people are affected. Sometimes there aren’t any symptoms, but leg swelling is often noted. If the clot breaks free, it will travel to the heart and then pass to the lung. This is called a pulmonary embolus or “PE.” When clotting is confined to the calf veins there isn’t much risk of PE because the small clots in the calf veins, even if they reach the lung, would not cause any symptoms. Therefore simple observation with ultrasound is recommended and many of these clots will resolve without treatment. For some patients with more extensive calf DVT, a blood thinner may be prescribed for 3-6 months to allow the body to absorb the clot and prevent extension of the clot and or propagation of clot.
When the veins behind the knee or in the thigh or pelvis are clotted, the risk of PE may be life-threatening. This is considered a “major” DVT. A great deal of work has been done and is still being done, to determine the best way to treat major DVT. In the past, blood thinners such as Heparin (intravenous) and Warfarin (oral medication) were the only recognized way to treat extensive DVT. Now there are other options.
1. Dissolution or removal of the clot. Surgery is risky and not effective in removing clots. There is also a significant rate of clot recurrence after surgery. This is why surgery is rarely done to treat DVT. Fortunately, there are many non-surgical ways to dissolve clots in the veins. While they don’t require surgery, they all require puncture and placement of a catheter. Often the clot can be dissolved or extracted in one session or overnight treatment. Many times, just before starting to remove or dissolve the clot we place a filter to catch any clots that would break off during treatment. This “filter” prevents large clots from passing through the heart and reaching the lung.
2. Use stents to treat underlying blockages. Often after dissolving and removing the clot we uncover a narrowing or blockage in the vein. We first use an angioplasty balloon to dilate this blockage and typically place a permanent stent or internal metal scaffold to hold the blockage open.
3. New oral anticoagulants. For years, Warfarin (Coumadin) was the only medication that could prevent recurrent DVT or extension of existing DVT. Now we have new agents that are approved for this indication. They are easy to give and don’t require weekly or monthly testing to adjust and maintain an adequate level of anticoagulation. However, they may not be “right” for everyone, so you should discuss their use with your interventional radiologist.
There is more information regarding DVT in a specific “What We Do” issue dedicated to this topic.